Provider Demographics
NPI:1336812890
Name:JACKSON, ELIZABETH (LPC-A)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 TUMBLEWEED TER
Mailing Address - Street 2:
Mailing Address - City:TAYLORS
Mailing Address - State:SC
Mailing Address - Zip Code:29687-5623
Mailing Address - Country:US
Mailing Address - Phone:803-807-7345
Mailing Address - Fax:
Practice Address - Street 1:127 W ANTRIM DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-2505
Practice Address - Country:US
Practice Address - Phone:864-239-4110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6927101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health